Fabricated or induced illness (FII) is a form of child maltreatment in which a parent or carer, usually the child's biological mother, seeks to convince professionals, usually doctors, that her child is unwell or more unwell than the child actually is. FII has been known as "Munchausen's syndrome by proxy" (not to be confused with Munchausen's syndrome, where a person pretends to be ill or causes illness or injury to themselves).
In nearly all cases, the child's mother is involved. The contribution of the father ranges from full responsibility with the mother to absence. Grandparents and other family members may support the mother. Foster carers may be involved.
The parent/carer mis-reports on aspects of her child’s state of health, by exaggerating, distorting or fabricating symptoms, history and diagnoses. Much more rarely, she also deliberately causes signs of illness in the child by interfering with investigations (e.g. putting sugar in the child’s urine) or causing illness in the child by poisoning (with e.g. salt or drug overdoses) or withholding medication. The intention is not to actually harm their child, but rather use their child.
It is difficult to estimate how widespread FII is because many cases, particularly those that do not involve actual induction of illness, may go unreported or undetected.
FII affects boys and girls equally. It is often only recognised later in a child’s life when professionals become increasingly curious and perplexed about the child’s presentations and discrepancies surrounding the history and the child’s presentation. It is only in retrospect that it can be seen that manifestations and alerting signs began early in a child’s life. It sometimes persists into adulthood, sometimes with the young person becoming to believe and perpetuate their erroneous sickness role. The child may well also have a verified illness or disability.
There are two different motivations for the mother’s behaviour. One is to obtain a gain from having her child being considered and treated as ill (or more ill), physically or psychologically. The gain can be attention, sympathy, support and may include financial or material gain. These mothers may well use deception. The other is to have confirmation of her erroneous beliefs about the child’s health. These wrong beliefs arise from misinformation from media, misinterpretation of the child's state of health, extreme concern/anxiety or, occasionally, delusional beliefs. These mothers do not use deception.
Some of the mothers have mental health disorders such as borderline personality disorder, health anxiety, somatoform disorders where they themselves genuinely experience multiple, recurrent physical symptoms with no underlying physical explanation; or they may have Munchausen Syndrome themselves.
The children are harmed by parental actions but also unintentionally by doctors who have to respond to symptom reporting. The child is harmed in several ways which include repeated examinations, investigations, sometimes treatments which might not be necessary and occasionally actual harm to their life; the child’s daily life is affected by e.g. poor school attendance and social isolation; and the child may be either very anxious about her/himself or wrongly believe that s/he is very ill.
FII is not usually recognised immediately. There are several alerting signs which suggest the possibility of FII. They include:
A single alerting sign does not by itself indicate possible FII. Once an alerting sign is recognized, others should be looked for.
If you think that there is immediate serious risk to the child’s health or life, which is rare, then you need to report this to children’s social care.
Otherwise, the alerting signs are now termed perplexing presentations. It is necessary for health services, usually led by a paediatrician or GP to establish the child’s actual state of health. If your job involves working with children, you should inform the person in your organisation who is responsible for child safeguarding of your concerns, and they will seek appropriate medical advice. It can be discussed with the parents that it is not clear to the professionals what is wrong with their child and this needs to be clarified. In most situations, open and honest communication works best. This process requires the sharing of information by all health and other services involved with the child, in order to agree a) that there is a health explanation for the reports about the child’s ill health and for the alerting signs or b) that the concerns about the harm to the child remain.
If concerns remain, this and the harm to the child needs to be explained to the parents. A rehabilitation plan is offered to the child and family.
If the parents are unable to work collaboratively with the rehabilitation plan, a referral to children’s social care is necessary in order to protect the child and help support a change in the damaging perceptions and behaviours that have caused harm to the child.
Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children